Assumptions about liver transplant wait-list mortality challenged

The majority of liver patients who die on, or are removed from, the transplant wait-list have declined an offer of transplant, show the findings of an American study.

Patients who died or were delisted received a median of six offers during the 5-year study period, with 84% receiving at least one offer of a transplant. This is despite the fact that over half of them had received at least one offer of a high-quality liver.

The findings contradict the assumption that wait-list mortality is due to lack of opportunity for transplant, and instead may be heavily influenced by declined transplantation.

The study included 33,389 candidates for liver transplant who had a Model for End-Stage Liver Disease (MELD) score of at least 15 at the end of the study.

By the end of the study, 20% had died or became too sick for transplant, 64% had undergone transplant, and 10% were still awaiting transplant. Overall, the authors considered only 28% of transplanted livers as high-quality.

In patients without hepatocellular carcinoma, those who died or were delisted had lower median MELD scores at their first offer (17 vs 20) but spent a longer time on the wait-list (median: 230 vs 60 days) and received more offers than patients who underwent transplant (median: six vs four).

The majority of livers that were initially declined and subsequently transplanted in another patient were listed as being refused due to "donor quality/age." Interestingly, 73% of high-quality livers were refused for this reason.

Additionally, when a high-quality liver was initially declined, the risk for graft failure with the subsequent transplant was similar to that seen when high-quality livers were accepted on the first offer.

The authors acknowledge that more detailed data are needed to fully understand why liver transplant offers are refused. However, they suggest that refusals could result from incomplete pre-transplantation workups, physician awareness and disclosure of donor-recipient relationships, and transplant center performance pressures.

John Roberts (University of California, San Francisco, USA) and colleagues say: "Simply increasing the availability of deceased donor livers or the number of offers may not substantially reduce wait-list mortality."

They insist that further research is vital but suggest that patient education and changes to how transplant centers are assessed could help improve outcomes for patients.

The authors conclude: "Efforts should be made in the transplant community to reduce the stigma associated with non-ideal livers and set realistic expectations for wait-listed candidates."

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